RadsDocDancer

Thursday, January 5, 2017

In 1972, philosopher-novelist Ayn Rand wrote an incredibly insightlful and inspiring essay dealing with the issue of what can be done to combat and try to help reverse what she perceived as a distressing American cultural decline on many levels, in innumerable ways over many generations. I slightly modified the text of her essay below < in brackets> to turn the issue to the US health care/ health insurance system which had been strangled by decades of government regulations even prior to going off the cliff under the suffocatingirrational decrees of ObamaCare- which the incoming administration and Congress have the power to undo. Whether they have the wisdom and will to do so - and the knowledge and political courage to implement much needed economically sound policies remains to be seen....."What Can One Do?"- by Ayn Rand"This question is frequently asked by people who are concerned about the state of < today's health care system > and want to correct it. More often than not, it is asked in a form that indicates the cause of their helplessness: "What can one person do?"I was in the process of preparing this article when I received a letter from a reader who presents the problem (and the error) still more eloquently: "How can an individual propagate < the correct ideas > on a scale large enough to effect the immense changes which must be made in order to create the kind of ideal social system < or health care system > which you picture?"If this is the way the question is posed, the answer is: he can't.No one can change a country single-handed. So the first question to ask is: why do people approach the problem this way?Suppose you were a doctor in the midst of an epidemic. You would not ask: "How can one doctor treat millions of patients and restore the whole country to perfect health?"You would know, whether you were alone or part of an organized medical campaign, that you have to treat as many people as you can reach, according to the best of your ability, and that nothing else is possible.People approach intellectual issues in a manner they would not use to deal with physical problems.They would not seek to stop an epidemic overnight, or to build a skyscraper single-handed. Nor would they refrain from renovating their own crumbling house, on the grounds that they are unable to rebuild the entire city.But in the realm of ideas, they still tend to regard knowledge as irrelevant, and they expect to perform instantaneous miracles, somehow or they paralyze themselves into inaction by projecting an impossible goal.If you are seriously interested in fighting for a better < health care system >, begin by identifying the nature of the problems.The battle is primarily intellectual (philosophical), not political. Politics is the *last consequence*, the practical implementation, of the fundamental philosophical ideas that dominate a given nation's culture.You cannot fight or change the consequences without fighting and changing the cause; nor can you attempt any practical implementation without knowing what you want to implement.In an intellectual battle, you do not need to convert everyone.History is made by minorities or, more precisely, history is made by intellectual movements, which are created by minorities.Who belongs to these minorities? Anyone who is able and willing actively to concern himself with intellectual issues. Here, it is not quantity, but quality that counts (the quality and consistency of the ideas one is advocating).An intellectual movement does not start with organized action. Whom would one organize?A philosophical battle is a battle for men's minds, not an attempt to enlist blind followers. Ideas can be propagated only by the men and women who understand them.An organized movement has to be preceded by an educational campaign, which requires trained- self-trained - teachers (self-trained in the sense that a philosopher can offer you the material of knowledge, but it is your own mind that has to absorb it).Such training is the first requirement for being a doctor during an ideological epidemic and the precondition of any attempt to "change the world.""The immense changes which must be made to < rationally reform the American health care system > cannot be made singly, piecemeal or "retail," so to speak; an army of crusaders would not be enough to do it.But the factor that underlies and determines every aspect of human life is philosophy; teach men the right ideas and their own minds will do the rest. Philosophy is the wholesaler in human affairs.Man cannot exist without some form of philosophy, i.e., some comprehensive view of life. Most men are not intellectual innovators, but they are receptive to ideas, are able to judge them critically and to choose the right course, when and if it is offered.There are also a great many men who are indifferent to ideas and to anything beyond the concrete-bound range of the immediate moment; such men accept subconsciously whatever is offered by the culture of their time, and swing blindly with any chance current.They are merely social ballast, be they day laborers or company presidents, and by their own choice, irrelevant to the fate of the world.Today, most people are acutely aware of our cultural-ideological vacuum <and the legal and economic chaos of our health care system>; they are anxious, confused, and groping for answers. Are you able to enlighten them?Can you answer their questions? Can you offer them a consistent case? Do you know how to correct their errors? Are you immune from the fallout of the constant barrage aimed at the destruction of reason <and freedom in our health care system>? Can you provide others with antimissile missiles?* A political battle is merely a skirmish fought with muskets; a philosophical battle is a nuclear war.*If you want to influence a country's intellectual trend <or bring rational reform to the health care system>, the first step is to bring order to your own ideas and integrate them into a consistent case, to the best of your knowledge and ability.This does not mean memorizing and reciting slogans and principles; knowledge necessarily includes the ability to apply abstract principles to concrete problems, to recognize the principles in specific issues, to demonstrate them, and to advocate a consistent course of action.This does not require omniscience or omnipotence; it is the subconscious expectation of automatic omniscience in oneself and in others that defeats many would-be crusaders (and serves as an excuse for doing nothing).What is required is honesty- intellectual honesty- which consists in knowing what one does know, constantly expanding one's knowledge, and never evading or failing to correct a contradiction. This means: the development of an active mind as a permanent attribute.When or if your convictions are in your conscious, orderly control, you will be able to communicate them to others.If you like condensations (provided you bear in mind their full meaning), I will say: when you ask "What can one do?" the answer is "SPEAK" (provided you know what you are saying).A few suggestions: do not wait for a national audience. Speak on any scale open to you, large or small, to your friends, your associates, <your patients>, your professional organizations, or any legitimate public forum.You can never tell when your words will reach the right mind at the right time. You will see no immediate results, but it is of such activities that public opinion is made.Do not pass up a chance to express your views on important issues. Write letters to the editors of newspapers and magazines, to TV and radio commentators and, above all, to your Congressmen (who depend on their constituents).If your letters are brief and rational (rather than incoherently emotional) they will have more influence than you suspect.The opportunities to speak are all around you. I suggest that you make the following experiment: take an ideological "inventory" of one week, i.e., note how many times people utter the wrong political, social and moral notions as if these were self-evident truths, with your silent sanction.Then make it a habit to object to such remarks. No, not to make lengthy speeches, which are seldom appropriate, but merely to say: "I don't agree." (And be prepared to explain why, if the speaker wants to know.) This is one of the best ways to stop the spread of vicious bromides.(If the speaker is innocent, it will help him; if he is not, it will undercut his confidence the next time.) Most particularly, do not keep silent when your own ideas and values are being attacked.Above all, do not join the wrong ideological groups or movements, in order to "do something". To join such groups means to reverse the philosophical hierarchy and to sell out fundamental principles for the sake of some superficial political action which is bound to fail. It means that you help the defeat of your ideas and the victory of your enemies.The only groups one may properly join today are ad hoc committees, i.e., groups organized to achieve a single, specific, clearly defined goal, on which men of differing views can agree.In such cases, no one may attempt to ascribe his views to the entiremembership, or to use the group to serve some hidden ideological purpose (and this has to be watched very, very vigilantly).I am omitting the most important contribution to an intellectual movement: writing. Books, essays, articles are a movement's permanent fuel, but it is worse than futile to attempt to become a writer solely for the sake of a "cause." Writing, like any other work, is a profession and must be approached as such.It is a mistake to think that an intellectual movement requires some special duty or self-sacrificial effort on your part. It requires something much more difficult: a profound conviction that ideas are important to you and to your own life. If you integrate that conviction to every aspect of your life, you will find many opportunities to enlighten others.It is too late for a movement of people who hold the conventional mixture of contradictory philosophical notions. It is too early for a movement of people dedicated to a philosophy of reason.But it is never too late or too early to propagate the right ideas- except under a dictatorship.If a dictatorship <or government run socialized medicine> ever comes to this country, it will be by the default of those who keep silent. We are still free enough to speak. Do we have time? No one can tell. But time is on our side because we have an indestructible weapon and an invincible ally (if we learn how to use them): reason and reality."What Can One Do?" by Ayn Rand< with personal editorial modifications inbracket >This appeared in original form in the Ayn Rand Letter, January 1972Published in " Philosophy: Who Needs It? "<NB: We also have other powerful tools at our disposal the awesome power of social media in disseminating ideas. If and when they speak out, doctors and other health care providers also have an the most importantand most powerful tool of all: the trust of patients for whom they personallyprovide life- giving and life-preserving medical care- and who trust their own doctor to make decisions that are in their best interest, while rightfully distrusting politicians, lawyers and today' s politically biased media.>

Friday, August 28, 2015

A thought-provoking article from February 2013 by Rituparna Basu debunks 2 popular misconceptions: 1) that the US health care and health insurance system operate according to a system of private property and free market principles, and 2) that ObamaCare is a system of "socialized" medicine. Rather, a careful look at the facts and history of US health care reveal a more ominous, little recognized, third alternative:

Of course, Obamacare did not deliver us socialized medicine, in which most hospitals would be owned by government and most doctors would be government employees. The majority of hospitals in America are still privately owned and so are insurers and drug companies. Many doctors are in private practice.

The government is the one calling the shots in health care today, dictating to those in the industry how they must run their businesses. And what’s crucial to know is that the government’s entrenchment in health care precedes Obamacare—health care has been a mostly controlled industry for decades.

A social system in which property is nominally privately owned but property rights can be overridden by government dictate is properly described as fascist, a term that became widespread in the 1920s to describe the system of state control in Mussolini’s Italy. According to one encyclopedia:

Under fascism, the state, through official cartels, controlled all aspects of manufacturing, commerce, finance, and agriculture. Planning boards set product lines, production levels, prices, wages, working conditions, and the size of firms. Licensing was ubiquitous; no economic activity could be undertaken without government permission.

This description is not far from the state of American health care today.

Saturday, January 31, 2015

The NYT's War on Doctor continues. The target is now doctors who provide less invasive stenting and endovascular services to restore normal arterial and venous blood flow in the setting of activity limiting pain, limb threatening conditions of low flow to limbs and vital abdominal organs. Used judiciously in the right circumstances, the procedure can be a much less expensive and safer alternative to surgical bypass surgery and is especially less expensive when performed by an independent doctor in a less expensive outpatient clinic, rather than a hospital. This has also opened the possibility to treating more patients safely, who were previously not good surgical candidates- hence the number of overall procedures and applications for the procedure has increased- as has the overall cost of doing more procedures. Of course, being as Medicare is already bankrupt, govt officials need a to create a new crisis and scapegoat to justify heavy handed measures to control the costs of their failed socialist health care policies. The trend today is for government officials and regulations to attempt to second guess doctors' medical judgement, refuse services outright or, more commonly, refuse or severely discount payments for services already rendered -even retroactively -and to push all procedures into the hospital - even though it can be over twice as expensive - and push all private doctors into bring salaried employees ie "fixed costs" to the government.Fewer necks to drop a yoke over, and you can then proceed to work them to death for the same and continually lower salary, rather than paying them for their services.

Enter the faceless, anonymous "medical expert" whose medical training, credentials, experience are never defined but left intentionally vague, yet somehow never in question - and who has never treated a patient, has no actual knowledge of your own case or of any specific case , but sits at a government computer and crunches statistics - and finds patterns of increasing popularity, utilization, implementation and subsequent _costs _ associated with new medical technologies - incontrovertible " proof" of fraud or malfeasance apparently requiring no further evidence or justification - and then manipulates them for political gain by socialist tinkers - working hand in hand with the NY Times and other liberal media rags to engage in a campaign of yellow jounalism:

"_Medical _experts _are questioning the necessity of some of these treatments, and many believe the condition is more safely treated with drugs and exercise. "

Modus operandi: select a rogue physician who is committing blatant fraud. When none can be found, create one - by choosing an "outlier". Use him in a smear campaign of sensationalism and public scare-mongering to tar and feather all doctors of his particular specialty- or doctors in general- as dangerous exploiters and victimizers of patients who need to be further controlled and regulated by regulators and bureaucrats. Use the actual or invented criminal to inculcate guilt in all doctors and create and nurture a public climate of distrust, suspicion, class envy, contempt and fear in all patients- and to prepare the groundwork for more and more regulation over all aspects of medical care by government regulators to ride in on white horses to "rescue" the public in the name of "public safety", "fiscal responsibility" , protection of vulnerable patients / taxpayers from greedy, exploiting profiteering doctors, etc....The goal is to demonize and criminalize private indpendent practitioners of outpatient medicine and chase them into the hospitals where they can be controlled under someone else's thumb who has oversight and veto authority on their excercise of their best medical judgment and rational thought in patient care. The best is when you can write Medicare regulations that are so voluminous, arcane , vague, restrictive or contradictory that no doctor can interpret them - let alone follow them. Then you can really cash in- and have doctors right where you want them: “Do you really think that we want those laws to be observed? … We want them broken. … There’s no way to rule innocent men. The only power any government has is the power to crack down on criminals. Well, when there aren’t enough criminals, one makes them. One declares so many things to be a crime that it becomes impossible for men to live without breaking laws. Who wants a nation of law abiding citizens? What’s there in that for anyone? But just pass the kind of laws that can neither be observed nor enforced nor objectively interpreted — and you create a nation of law-breakers — and then you cash in on guilt.”— Dr. Floyd Ferris in Ayn Rand’s Atlas Shrugged, Part II, Chapter IIIhttp://www.nytimes.com/2015/01/30/business/medicare-payments-surge-for-stents-to-unblock-blood-vessels-in-limbs.html?_r=0

The government's heavy handed government control of doctors in fact bears a striking resemblance to methods employed in post Soviet Russia by loyal party apparatchiks hell bent on sabotaging free market and democratic political reforms, while maintaining control of the reins of power while laying the groundwork for Putin 's present day kleptocracy:

"That corruption was part of the [ post - Soviet] Russian system from the beginning is something we’ve long known for a long time, of course. In her book Sale of the Century (2000), Chrystia Freeland memorably describes the moment when she realized that the confusing regulations and contradictory laws that hog-tied Russian business in the 1990s were not a temporary problem that would soon be cleaned up by some competent administrator.

On the contrary, they existed for a purpose: the Russian elite wanted everybody to operate in violation of one law or another, because that meant that everybody was liable at any time to arrest. The contradictory regulations were not a mistake, they were a form of control."

Monday, December 29, 2014

So Congress went ahead and passed the "Affordable" Care Act bill....so that we could find out what's in it....and now that we know, it's pretty clear that it's not so great at making health care "affordable" . It's pretty bad, actually - and soon to get worse - for doctors . In fact, it's even worse for patients.

So who is it good for? Richard Lenzner gave us a pretty good clue back in late 2013 here:

" So far in 2013 the value of the S& Phealthinsurance index has gained 43%. Thats more than double the gains made in the broad stock market index, the S & P 500. The shares of CIGNA are up 63%, Wellpoint 47% and United Healthcare 28%. And if you go back to the early 2010 passage of ObamaCare, you will find that Obama’s sellout of the public interest has allowed the public companies the ability to raise their premiums, especially on small business, dramatically multiply their profits and send the value of their common stocks up by 200 % - 300 %...

We warned you back on December 4, 2009 in my blog ” The Horrendous Truth About Health Care Reform” that the Obama White House was handing a “ free ride for the health insurance industry” that would allow premium hikes of 8%-10% a year by CIGNA, HumanaHUM-0.41%, AetnaAET-0.1%, UnitedHealth GroupUNH-0.21% and Wellpoint, and as well a $500 billion taxpayer subsidy, a half trillion dollars without any requirement that the health insurers had to spend the subsidy on medical care...

At the time I wrote, Goldman Sachs research operation estimated that the 5 giants would increase profits by 10% a year from 2010 to 2019, sending their shares up an average of 59%. In truth, the shares of CIGNA and some others are up a multiple of several times since the contest was resolved by a very tight vote in early 2010...." ( it should be noted that the current stock price of each of the above companies is well above *100%* of what it was is 2013... )

And so, in 2015, with insurance companies flush with cash, perhaps there will be a precipitous drop in health care premiums as companies pass their windfall profits along to their customers? Not according to the below NY Timesarticle:

"The Obama administration on Friday unveiled data showing that many Americans with health insurance bought under the Affordable Care Act could face substantial price increases next year — in some cases as much as 20 percent — unless they switch plans.

The data became available just hours before the health insurance marketplace was to open to buyers seeking insurance for 2015..."

To what do US health insurance companies owe their extraordinary profits? To life-saving discoveries? Productivity- enhancing innovation? Exemplary, competition -crushing customer service and satisfaction? No, in a word, to "cronyism". For a look at the sordid face of on-going health insurance cronyism since the run-up to ObamaCare :"Our story begins just days after Obama’s landslide victory over Sen. John McCain (R-AZ) in 2008. Sensing an opportunity to increase profits at taxpayer expense, Karen Ignagni, the president of America’s Health Insurance Plans (the trade association that represents the health insurance industry in Washington), quickly signaled that she was ready to do business with the new occupant of the White House.

“No one should fall through the cracks of our health care system,” Ignagni’s November 11, 2008 statement read. “Universal coverage is within reach and can be achieved by building on the current system.”

That last phrase, “and can be achieved by building on the current system” was the health insurance industry’s top priority in the beginning of the Obama administration. And they spent furiously to make sure Obama would protect them. Despite the worst recession since World War II, businesses spent more than $1 billion lobbying on health reform in 2009, a sharp increase from 2008.

Blue Cross/Blue Shield led the league in lobbyist spending, shelling out $15.13 million in 2009, up more than 25 percent from 2008. AHIP shelled out another $8.85 million, while United Health Group added $4.86 million, and Aetna Inc. spent $2.84 million.

These millions turned out to be very wise investments. Health industry lobbyists secured dozens of meetings in the White House throughout 2009 and 2010. They not only met with Obama’s top advisers, but also Obama himself.

These meetings had a very clear impact on the policy that Obama would eventually produce. During a June 24, 2009 ABC News town hall meeting on health care, Obama assured the CEO of Aetna: “Aetna is a well-managed company and I am confident that your shareholders are going to do well.”

And Aetna has done more than “well” under Obamacare. Its stock price has more than doubled, and almost tripled, since Obama publicly promised the company it would “do well” under Obamacare.

And when you look at the basic outline of Obamacare, you can see exactly why. The program forces every American to buy the health insurance industry’s products and also subsidizes those purchases to the tune of more than $1 trillion over just the next decade alone. No wonder health insurance industry stocks are booming.

But the relationship between the health insurance industry and the Obama administration did not end on March 23, 2010, the day Obamacare was signed into law. If anything, it was just beginning...."

The good news is that now, you can potentially win $1000 and help your health insurance executive and/or elected representative get the recognition he or she deserves- by nominating him for the2015 Atlas Shrugged Crony Awards:

"Crony capitalism is not true capitalism. What we have today is a system in which government intervenes in every sector of the economy, through subsidies and regulations, creating opportunities for businesses to profit from government favors.

No business today can avoid dealing with government. Still, there’s a difference between those who aim to create goods or services and succeed through market competition, for whom the struggle to navigate the shoals of regulations and permissions is a sideline; and those for whom deals with politicians and bureaucrats are the essence of what they do. Not always an easy distinction to draw. But the Atlas Shrugged Crony Awards are intended to spotlight the clearest and most egregious cases of these “political” entrepreneurs.

Cases of cronyism involve a business on one side, government on the other (often with a lobbyist or other middle-man). The Contest is open to both sides of that equation. To qualify for the contest, nominees should meet the following criteria:

Business: The business lobbies to create and benefit from a special government subsidies, tax breaks, or other privilege or regulation limiting competitors. And the business promotes and benefits from favoritism with government officials.

Government: The politician or other official uses discretionary power to confer a benefit on a business in expectation of personal benefit, or in a manner that is covert and based on a special relationship with the business.

In short, Crony Capitalism is an effort to seek gain through government rather than the market."

Saturday, August 30, 2014

In honor of Labor Day, I took the personal license to make a few editorial modifications to Francisco d'Anconia's warning from Atlas Shrugged by Ayn Rand. In light of the rapidly progressing bureaucratic mess, suffocating regulation and skyrocketing costs foisted on the American public and medical community by the dishonestly named "Affordable Care Act", the below seems particularly timely and applicable.

If you haven't read the book yet, I highly recommend it - especially if you are a doctor (or other health care provider), a current patient, or a future patient. (Please take note: if you haven't noticed, the last category includes everyone).

Don' t content yourself with the upcoming movie - the book is far superior and comprehensive. If you undertake the challenge (definitely far more rewarding than dumping a bucket of ice on your head- as well as more eye opening, mind opening, and mentally invigorating), I promise you will be richly rewarded with many, many valuable insights such as provided below:

"When you see that (patient care) is done, not by consent, but by compulsion - when you see that in order to (practice medicine), a doctor needs to obtain permission from men who produce nothing - when you see money flowing to those who deal, not in (medical services) but in favors - when you see that men get richer by graft and pull than by work, and your laws don't protect you against them, but protect them against you - when you see corruption ( and bureaucracy) being rewarded and honesty (and patient care) becoming a self-sacrifice - you may know that your (own personal health and health care system) are doomed."

Tuesday, April 29, 2014

To the person on the street, everything seems to be changing on an almost daily basis. How can the ordinary person begin to understand all the ramifications of the Affordable Care Act? What is a person to do when, even though they have health insurance, they are potentially facing high medical bills that are not addressed by their plan?

Some people with a high deductible plan end up having to pay thousands of dollars in co-pays and deductibles. Are there other options for them or ways they can get discounted services? Or maybe they have seen a doctor out-of-network, or for some reason their condition is not addressed by their health insurance. What are they to do?

"When the government takes over health care and bans private health insurance, what can we expect? We can expect rationing of medical care.

In fact, in the New York Times article below, leftist utilitarian philosopher Peter Singer openly advocates rationing. He does it by arguing that health care is already "rationed" in the free market, it is just "rationing by price."

This is an inexcusable abuse of the language. "Rationing by price" is a contradiction in terms, because prices are the opposite of rationing.

The essence of a price is voluntary exchange. A price is the result of a negotiation between a willing buyer and a willing seller, with each party acting on his own judgment about his best interests.

So if you decide to pay lower premiums for less extensive insurance coverage, or to forgo an extremely expensive treatment that will only extend your life by a few months, so that you can leave more of your savings to your loved ones, these vital decisions are under your control and are directed according to your judgment of the risks and of the relative values involved.

You are never denied care-if you are actually willing to do what is necessary to obtain it.

Prices are implicitly based on an ethics of individualism-the idea that it is the individual's right to make his own decisions and his responsibility to support himself.

Rationing, by contrast, is an artificial shortage created by coercion.

It consists of the government telling you that you cannot have certain kinds of medical care because some board of bureaucrats has decided that it is not "cost-effective."

Rationing is implicitly-and explicitly-based on an ethics of collectivism.

I don't recommend reading the whole article below, because reading a contemporary philosopher is like sticking your head in a cotton candy machine. But if you do choose to read it, you may notice that it never looks at medical care from the perspective of the individual making rational decisions about costs and benefits for his own life.

It always implicitly looks at health care from a collectivist perspective: the perspective of bureaucrats making decisions about the cost of your medical care "to society."

The term that sums up this collectivist outlook is the "quality adjusted life year"-the pseudo-mathematical term for a government bureaucrat's decision concerning whether your life is worth continuing or not, based upon your age, your prognosis, and some bureaucratic formula that quantifies your "quality of life."

"Quality adjusted life year" is the term that tells you that the most profound decisions concerning your own life have been taken out of your hands. Get ready to hear it a lot- and to live and die by it- if Obama and the Democratic leaders in Congress get their way.

"Why We Must Ration Health Care," Peter Singer, New York Times, July 15

"You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much? If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn't going to be good. But suppose it's not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man-and everyone else like him-with Sutent, your premiums will increase.

Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone's life?

If there is any point at which you say, "No, an extra six months isn't worth that much," then you think that health care should be rationed.

In the current US debate over health care reform, "rationing" has become a dirty word .

Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for.

But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.

The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages.

In May, Medicare's trustees warned that the program's biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation .

Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won't be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money.

The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?...

This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care.

The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money.

If a reformed US health care system explicitly accepted rationing, as I have argued it should, QALYs could play a similar role in the US..The Tracinski Letter